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1、Pre ICU training ARF & CRRT,林承叡May 19, 2007,Definition of ARF,rapid decrease the renal function or urine output Cr0.5mg/dl, or Cr50%, or GFR50%,(1) Prerenal ARF, prerenal azotemia(-55%) diseases/that cause renal hypoperfusion without compromising integrity of renal parenchyma (2) intrinsic renal ARF
2、, renal azotemia (-40%) diseases that directly involve renal parenchyma (3) postrenal ARF, postrenal azotemia (-5%). diseases associated with urinary tract obstruction,Indications for dialysis,Clinical evidence (symptoms or signs) of uremiaIntractable intravascular volume overloadHyperkalemia or sev
3、ere acidosis resistant to conservative measuresProphylactic dialysis when urea 100-150 mg/dL or creatinine 8-10 mg/dL,CRRT,AV: arteriovenous circuit VV: venovenous circuit Convection technique: UF, Hemofiltration Diffusion technique: solute gradient HDF: hemodiafiltration: small and middle molecules
4、,CAVH (continuous arteriovenous hemofiltraton), CAVHD (continuous arteriovenous hemodialysis), CVVH (continuous venous-venous hemodialysis), CVVHD (continuous venous-venous hemodialysis),SCD (slow continuous dialysis) 目前以CVVHD最為普遍。 使用擴散(diffusion)或對流(convection)原理來去除尿毒及多餘的水份、代謝廢物。,CRRT,可適用於以下的病症 (2)
5、 *葯物中毒 *嚴重乳酸鹽中毒 *敗血病休克 (SEPTIC SHOCK) *體溫過高/發熱 (HYPERTHERMIA) *橫紋肌溶解 (RHABDOMYOLISIS) 導致血液甚至尿液有過量肌球蛋白 (MYOGLOBULIN) *急性溶血 *細菌中毒,Indications,In critically ill patients with renal failure and hemodynaemic instabilityFor patients in whom continuous removal of volume or toxic substance is desirable ( as
6、 in septic shock , AMI , severe GI bleeding ,ARDS or condition with or at risk for cerebral edema .),血管通路:CVVHD較CAVHD安全，不會引起動脈阻塞、出血、及栓塞。但是使用CVVHD則要注意是否有空氣跑入，或管路連接脫落導致大量出血。,透析器：一般使用高透量(high flux)的短型人工腎臟，當然傳統的人工腎臟透析器也可使用。,補充液及透析液：可以使用一般腹膜透析的含1.5%葡萄糖透析液，或CAVHD專用；或自己泡製。但要注意其中電解質的平衡，如鈉140mEq/L、鉀2.0 mEq/L
7、、鈣 3.5 mEq/L、鎂 1.5 mEq/L。如用碳酸鹽，則要避免與鈣質產生沈澱。透析液流速每小時以1000ml為原則，視所須過濾之水份多少加以調整。,連續性腎替代性治療(CRRT) 的併發症,(1)出血 (2)凝固 (3)失溫 (4)逆過瀘 (backfiltration) (5)水份及電解質不平衡 (6)通路脫落等,Procedure共同處,Driving force : external pump Circuit : Venovenous Dialysis solutions :一般使用1.5% PD solution Replacement fluid : several type
8、s of replacement fluid can be used , depending on patient requirements ,一般使用 pre-dilution 方式.,Anti-coagulation 的方式,STANDARD HEPARIN TYPICAL REGIMEN IN CRRT : Priming of the circuit ( 5000 IU / L ) Initial Heparin Bolus : 5 - 8 IU / kg Infuse Heparin at : 5 to 12 IU / kg / hr ACT on post filter : Adj
9、ust heparin rate to keep ACT between 1.5 & 2.0 times,STANDARD HEPARIN,ADVANTAGES Easy to perform Useful method Inexpensive,DISADVANTAGES Occasional Thrombocytopenia Hemorrhagic Risk with Bleeding patient,LOW MOLECULAR WEIGHT (LMW) HEPARIN,TYPICAL REGIMEN IN CRRT : Priming of the circuit : 20 mg in 1
10、 L Maintenance dose : 10 to 40 mg q6 hrsMonitor anti- factor Xa (aXa) units . Adjust between 0.1 and 0.4 /ml Different Dosages for LMW heparin,LOW MOLECULAR WEIGHT (LMW) HEPARIN,ADVANTAGES Decreased Risk of Bleeding,DISADVANTAGES Expensive Special and difficult monitoring With low doses frequent fil
11、ter clotting,Regional Citrate Anticoagulation,TYPICAL REGIMEN : Citrate anticoagulation is always regional Citrate infusion (4%) at 170 ml/hr initially Special Dialysate at 1 liter/hr ( Na+ 117 , K+ 4 , Mg+ 1.5 , Cl- 121.5 , dextrose 0.5- 2.5% , no Ca+ , no base ) CaCL2 (0.75%) by central I.V at 40-
12、60 ml/hr, Maintain ionized Ca+ at 0.96- 1.20 mmol/L,Citrate,ADVANTAGES : No Bleeding No Thrombocytopenia Improved Filter Life and Efficacy,DISADVANTAGES : Complex for the set up Ca+ monitoring needed Occasional Alkalosis,Heparin- free methods,Normal saline flush Used in patients with1. Severe liver
13、disease 2. Acitve or recent bleeding 3. Heparine-induced thrombocytopenia4. Post-op patients,Dialysis modalities in the ICU,CVVH配置簡圖,CVVH Continuous Veno-Venous Hemofiltration,CVVH 模式下, 置換液流速 最高可達4500ml/hr,CVVH order,l Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l For AK
14、 priming: (GAMBRO, Polyarylethersulfone, 6S)*1st N/S 1000cc.*2nd Heparin 2,500U.*3rd N/S 500cc. l *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr)2.5 - 60min -4,CVVH order,If non-heparin , N/S 200cc q hr to rinse the AK
15、 Predilution run 500cc/hr alternately as followed via artery end1st bottle N/S 500cc + Sinca 1amp2nd bottle N/S 500cc + 10% MgSO4 4cc3rd bottle N/S 500cc 4th bottle D5W 500cc + NaHCO3 5amp Warm dialysate to 37C Record I/O and BP q1hr UF target I-O ( ) cc/hrCheck BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day
16、& then q8hr. Check Ca,P,Mg qd.,CVVHD配置簡圖,CVVHD Continuous Veno-Venous Hemodialysis,CVVHD order,l Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6S)*1st N/S 1000cc.*2nd Heparin 2,500U.*3rd N/S 500cc. l *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr)2.5 - 60min -4,
